1250 SE Maynard Road, Ste. 204
Cary, NC 27511
The patient has been registered as Self-Pay due to the following reason marked below:
The patient/Financial Power of Attorney does not have insurance coverage OR
The provider performing the above services or therapies is not a participating provider with my health insurance. Therefore, these services/therapies are not covered by my policy.
It is my personal decision not to obtain the authorization from my primary care physician and not to have Silver Linings obtain it on my behalf. I agree to pay Silver Linings for services.
My signature below acknowledges receipt and acceptance of the Self Pay Agreement